Sports Medicine

, Volume 41, Issue 5, pp 401–411

Is the ‘Athlete’s Heart’ Arrhythmogenic?

Implications for Sudden Cardiac Death
Review Article

Abstract

Whether the ventricular hypertrophic response to athletic training can predispose to fatal ventricular dysrhythmias via mechanisms similar to that of pathological hypertrophy is controversial. This review examines current information regarding the metabolic and electrophysiological differences between the myocardial hypertrophy of heart disease and that associated with athletic training. In animal studies, the biochemical and metabolic profile of physiological hypertrophy from exercise training can largely be differentiated from that of pathological hypertrophy, but it is not clear if the former might represent an early stage in the spectrum of the latter. Information as to whether the electrical remodelling of the athlete’s heart mimics that of patients with heart disease, and therefore serves as a substrate for ventricular dysrhythmias, is conflicting. If ventricular remodelling associated with athletic training can trigger fatal dysrhythmias, such cases are extraordinarily rare and thereby impossible to investigate by any standard experimental approach. Greater insight into this issue may come from a better understanding of the electrical responses to both acute bouts of exercise and chronic training in young athletes.

References

  1. 1.
    Rost R. The athlete’s heart. What did we learn from Henschen, what Henschen could have learned from us!J Sports Med Phys Fitness 1990; 30: 339–46Google Scholar
  2. 2.
    Shephard RJ. The athlete’s heart: is big beautiful? Br J Sports Med 1996; 30: 5–10PubMedCrossRefGoogle Scholar
  3. 3.
    Thompson PD. Historical concepts of the athlete’s heart. Med Sci Sports Exerc 2004; 36: 363–70PubMedCrossRefGoogle Scholar
  4. 4.
    Furlanello F, Bertoldi A, Bettini R, et al. Life-threatening tachyarrhythmias in athletes. PACE 1992; 15: 1403–11PubMedGoogle Scholar
  5. 5.
    Heidbuchel H, Hoogsteen J, Fagard R, et al. High prevalence of right ventricular involvement in endurance athletes withventricular arrhythmias. Eur Heart J 2003; 24: 1473–80PubMedCrossRefGoogle Scholar
  6. 6.
    Palatini P, Scanavacca G, Bongiovi S, et al. Prognostic significance of ventricular extrasystoles in healthy professional athletes:results of a 5-year follow-up. Cardiology 1993; 82: 286–93PubMedCrossRefGoogle Scholar
  7. 7.
    Rowland T. Sudden unexpected death in young athletes: reconsidering “hypertrophic cardiomyopathy”. Pediatrics 2009; 123: 1217–22PubMedCrossRefGoogle Scholar
  8. 8.
    Hart G. Exercise-induced cardiac hypertrophy: a substrate for sudden death in athletes? Exp Physiol. 2003; 88: 639–44PubMedCrossRefGoogle Scholar
  9. 9.
    Varro A, Baczko I. Possible mechanisms of sudden death in top athletes: a basic cardiac electrophysiological point ofview. Pflugers Arch 2010; 460: 31–40PubMedCrossRefGoogle Scholar
  10. 10.
    Maron BJ, Pelliccia A. The heart of trained athletes: cardiac remodeling and the risk of sports, including sudden death. Circulation 2006; 114: 1633–44PubMedCrossRefGoogle Scholar
  11. 11.
    Grossman W, Jones D, McLaurin LP. Wall stress and patterns of hypertrophy in the human left ventricle. J Clin Invest 1975; 56: 56–64PubMedCrossRefGoogle Scholar
  12. 12.
    Oparil S. Pathogenesis of ventricular hypertrophy. Am Coll Cardiol 1985; 5: 57–65BCrossRefGoogle Scholar
  13. 13.
    Ford LE. Heart size. Circ Res 1976; 39: 297–303PubMedCrossRefGoogle Scholar
  14. 14.
    Lips DJ, deWindt LJ, van Kraaij DJW, et al. Molecular determinants of myocardial hypertrophy and failure:alternative pathways for beneficial and maladaptive hypertrophy. Eur Heart J 2003; 24: 883–96PubMedCrossRefGoogle Scholar
  15. 15.
    Catalucci D, Latronico MVG, Ellingsen O, et al. Physiological myocardial hypertrophy: how and why? Frontiers Bioscience 2008; 13: 312–24CrossRefGoogle Scholar
  16. 16.
    Dorn GW. The fuzzy logic of physiological cardiac hypertrophy. Hypertension 2007; 49: 962–70PubMedCrossRefGoogle Scholar
  17. 17.
    Haider AW, Larson MG, Benjamin EJ, et al. Increased left ventricularmass and hypertrophy are associated with increasedrisk for sudden death. J Am Coll Cardiol 1998; 32: 1454–9PubMedCrossRefGoogle Scholar
  18. 18.
    Ghali JK, Kadakia S, Cooper RS, et al. Impact of left ventricular hypertrophy on ventricular arrhythmias in the absenceof coronary artery disease. J Am Coll Cardiol 1991; 17: 1277–82PubMedCrossRefGoogle Scholar
  19. 19.
    Cooklin M, Wallis WRJ, Sheridan DJ, et al. Changes in cellto- cell electrical coupling associated with ventricular hypertrophy. Circ Res 1997; 80: 665–71CrossRefGoogle Scholar
  20. 20.
    Hart G. Ceullular electrophysiology in cardiac hypertrophy and failure. Cardiovasc Res 1994; 28: 933–46PubMedCrossRefGoogle Scholar
  21. 21.
    Swynghedauw B. Molecular mechanisms of myocardial remodeling. Physiol Rev 1999; 79: 215–62PubMedGoogle Scholar
  22. 22.
    Winckels SKG, Vas MA. Ventricular electrical remodeling in compensated cardiac hypertrophy. In: Wilde AAM, Friedman PA, Ackerman MJ, et al., editors. Electricaldiseases of the heart. London: Spring Verlag, 2008: 305–15CrossRefGoogle Scholar
  23. 23.
    Aquilar JC, Martinez AH, Conejos FA. Mechanisms of ventricular arrhythmias in the presence of pathologicalhypertrophy. Eur Heart J 1993; 14: 65–70CrossRefGoogle Scholar
  24. 24.
    Pye MP, Cobbe SM. Mechanisms of cardiac arrhythmias in cardiac failure and hypertrophy. Cardiovasc Res 1992; 26: 740–50PubMedCrossRefGoogle Scholar
  25. 25.
    Swynghedauw B, Ballard C, Milliez P. The long QT interval is not only inherited but is also linked to cardiac hypertrophy. J Mol Med 2003; 81: 336–45PubMedGoogle Scholar
  26. 26.
    Antoons G, Oros A, Bito V, et al. Cellular basis for triggered ventricular arrhythmias that occur in the setting of compensatedhypertrophy and heart failure: considerations fordiagnosis and treatment. J Electrocardiol 2007; 40: S8–14PubMedCrossRefGoogle Scholar
  27. 27.
    Neyses L, Pelzer T. The biological cascade leading to cardiac hypertrophy. Eur Heart J 1995; 16 Suppl.N: 8–11CrossRefGoogle Scholar
  28. 28.
    Morganroth J, Maron BJ, Henry WL, et al. Comparative left ventricular dimensions in trained athletes. Ann Intern Med 1975; 82: 521–4PubMedGoogle Scholar
  29. 29.
    Pluim BM, Zwinderman AH, van de Laarse A, et al. The athlete’s heart: a meta-analysis of cardiac structure andfunction. Circulation 1999; 100: 336–44Google Scholar
  30. 30.
    Naylor LH, George K, O’Driscoll G, et al. The athlete’s heart: a contemporary appraisal of the ‘Morganrothhypothesis’. Sports Med 2008; 38: 69–90PubMedCrossRefGoogle Scholar
  31. 31.
    Wakatsuki T, Schlessinger J, Elson EL. The biochemical response of the heart to hypertension and exercise. Trends Biochem Sci 2004; 29: 609–17PubMedCrossRefGoogle Scholar
  32. 32.
    Shave R, George K, Whyte G, et al. Postexercise changes in left ventricular function: the evidence so far. Med Sci Sports Exerc 2008; 40: 1393–9PubMedCrossRefGoogle Scholar
  33. 33.
    Alpert MA. Obesity cardiomyopathy: pathophysiology and evolution of the clinical syndrome. Am J Med Sci 2001; 321: 225–36PubMedCrossRefGoogle Scholar
  34. 34.
    Opie LH, Commerford PJ, Gersh BJ, et al. Controversies in ventricular remodeling. Lancet 2006; 367: 356–67PubMedCrossRefGoogle Scholar
  35. 35.
    Tibbits GF, Barnard RJ, Baldwin KM, et al. Influence of exercise on excitation-contraction coupling in rat myocardium. Am J Physiol 1981; 240: H472–80PubMedGoogle Scholar
  36. 36.
    Gwathmey JK, Slawsky MT, Perreault CL, et al. Effect of exercise conditioning on excitation-contraction couplingin aged rats. J Appl Physiol 1990; 69: 1366–71PubMedGoogle Scholar
  37. 37.
    Hanne-Paparo N, Drory Y, Schoenfeld Y, et al. Common ECG changes in athletes. Cardiology 1976; 61: 267–78PubMedCrossRefGoogle Scholar
  38. 38.
    Palatini P, Maraglino G, Sperti G, et al. Prevalence and possible mechanisms of ventricular arrhythmias in athletes. Am Heart J 1985; 110: 560–7PubMedCrossRefGoogle Scholar
  39. 39.
    Sharma S, Whyte G, Elliott P, et al. Electrocardiographic changes in 1000 highly trained junior athletes. Br J Sports Med 1999; 33: 319–24PubMedCrossRefGoogle Scholar
  40. 40.
    Stolt A, Kujala UM, Karjalainen J, et al. Electrocardiographic findings in female endurance athletes. Clin J Sport Med 1997; 7: 85–9PubMedCrossRefGoogle Scholar
  41. 41.
    Van Ganse W, Versee L, Eylenbosch W, et al. The electrocardiogram of athletes: comparison with untrained subjects. Br Heart J 1970; 32: 160–4PubMedCrossRefGoogle Scholar
  42. 42.
    George KP, Wolfe LA, Burggraf GW, et al. Electrocardiographic and echocardiographic characteristics of femaleathletes. Med Sci Sports Exerc 1995; 27: 1362–70PubMedGoogle Scholar
  43. 43.
    Heinz L, Sax A, Robert F, et al. T-wave variability detects abnormalities in ventricular repolarization: a prospectivestudy comparing healthy persons and Olympic athletes. Ann Noninvasive Eectrocardiol 2009; 14: 276–9CrossRefGoogle Scholar
  44. 44.
    Jordaens L, Missault L, Pelleman G, et al. Comparison of athletes with life-threatening ventricular arrhythmia withtwo groups of healthy athletes and a group of normalcontrol subjects. Am J Cardiol 1994; 74: 1124–8PubMedCrossRefGoogle Scholar
  45. 45.
    Langdeau JB, Blier L, Turcotte H, et al. Electrocardiographic findings in athletes: the prevalence of left ventricular hypertrophyand conduction defects. Can J Cardiol 2001; 17: 655–9PubMedGoogle Scholar
  46. 46.
    Rajappan K, O’Connell C, Sheridan DJ. Changes in QT interval with exercise in elite male rowers and controls. IntJ Cardiol 2003; 87: 217–22CrossRefGoogle Scholar
  47. 47.
    Zoghi M, Gurgun C, Yavuzgil O, et al. QT dispersion in patients with different etiologies of left ventricular hypertrophy:the significance of QT dispersion in enduranceathletes. Int J Cardiol 2002; 84: 153–9PubMedCrossRefGoogle Scholar
  48. 48.
    Halle M, Huonker M, Hohnloser SH, et al. QT dispersion in exercise-induced ventricular hypertrophy. Am Heart J 1999; 138: 309–12PubMedCrossRefGoogle Scholar
  49. 49.
    Mayet J, Kanagarantnam P, Kanagarantnam P. QT dispersion in athletic left ventricular hypertrophy. Am Heart J 1999; 137: 678–81PubMedCrossRefGoogle Scholar
  50. 50.
    Turkmen M, Barutcu I, Esen AM, et al. Assessment of QT interval duration and dispersal in athlete’s heart. Int J Med Res 2004; 32: 626–32Google Scholar
  51. 51.
    Lawan A, Ali MA, Bauchi SSD. QT dispersion in dynamic and static group of athletes. Nig J Physiol Sci 2006; 21: 5–8Google Scholar
  52. 52.
    Munir DF, Love NWA, McCann GP, et al. Athletic ventricular hypertrophy is associated with increased QT dispersion[abstract]. Am Heart J 1999; 33 Suppl.A: 2Google Scholar
  53. 53.
    Tanriverdi H, Kaftan HA, Evrengul H, et al. QT dispersion and left ventricular hypertrophy in athletes: relationshipwith angiotensin-converting enzyme I/D polymorphism. Acta Cardiol 2005; 60: 387–93PubMedCrossRefGoogle Scholar
  54. 54.
    Corrado D, Basso C, Rizzoli G, et al. Does sports activity enhance the risk of sudden death in adolescents and youngadults. JAMA 2003; 42: 1959–63Google Scholar
  55. 55.
    Bjornstad H, Storstein L, Meen HD, et al. Ambulatory electrocardiographic findings in top athletes, athletic studentsand control subjects. Cardiology 1994; 84: 42–50PubMedCrossRefGoogle Scholar
  56. 56.
    Campbell RWF. Ventricular arrhythmias in normal individuals and athletes. Eur Heart J 1988; 9 Suppl.G: 113–7PubMedCrossRefGoogle Scholar
  57. 57.
    Pilcher GF, Cook J, Johnston BL, et al. Twenty-four hour continuous electrocardiography during exercise and freeactivity in 80 apparently healthy runners. Am J Cardiol 1983; 52: 859–61PubMedCrossRefGoogle Scholar
  58. 58.
    Talan DA, Bauernfeind RA, Ashley WW, et al. Twenty-four hour continuous ECG recordings in long-distance runners. Chest 1982; 82: 19–24PubMedCrossRefGoogle Scholar
  59. 59.
    Viitsalo M, Kala R, Eisalo A. Ambulatory electrocardiographic recording in endurance athletes. Br Heart J 1982; 47: 213–20CrossRefGoogle Scholar
  60. 60.
    Pantano JA, Oriel RJ. Prevalence and nature of cardiac arrhythmias in apparently normal well-trained runners. Am Heart J 1982; 104: 762–8PubMedCrossRefGoogle Scholar
  61. 61.
    Biffi A, Maron BJ, Di Giacinto B, et al. Relation between training-induced left ventricular hypertrophy and risk forventricular tachyarrhythmias in elite athletes. Am J Cardiol 2008; 101: 1792–5PubMedCrossRefGoogle Scholar
  62. 62.
    Biffi A, Maron BJ, Verdile L, et al. Impact of physical deconditioning on ventricular tacharrhythmias in trainedathletes. J Am Coll Cardiol 2004; 44: 1053–8PubMedCrossRefGoogle Scholar
  63. 63.
    Biffi A, Pelliccia A, Verdile L, et al. Long-term clinical significance of frequent and complex ventricular tachyarrhythmias intrained athletes. J Am Coll Cardiol 2002; 40: 446–52PubMedCrossRefGoogle Scholar
  64. 64.
    Billman GE. Cardiac autonomic neural remodeling and suspectibility to sudden cardiac death: effect of enduranceexercise training. Am J Physiol Heart Circ Physiol 2009; 297: H1171–93PubMedCrossRefGoogle Scholar
  65. 65.
    Maron BJ, Roberts WC, Epstein SE. Sudden death in hypertrophic cardiomyopathy: a profile of 78 patients. Circulation 1982; 65: 1388–94PubMedCrossRefGoogle Scholar
  66. 66.
    Maron BJ, Shrani J, Poliac JC, et al. Sudden death in young competitive athletes: clinical, demographic, and pathologicalprofiles. JAMA 1996; 276: 199–204PubMedCrossRefGoogle Scholar
  67. 67.
    Maron BJ, Pellicia A, Spirito P. Cardiac disease in young trained athletes. Circulation 1995; 91: 1596–601PubMedCrossRefGoogle Scholar
  68. 68.
    Mueller FO, Cantu RC, Van Camp SP. Catastrophic injuries in high school and college sports. Champaign (IL): Human Kinetics, 1996: 23–9Google Scholar
  69. 69.
    Rowland T, Roti M. Influence of sex on the “athlete’s heart” in trained cyclists. J Sci Med Sport 2010; 13 (5): 475–8PubMedCrossRefGoogle Scholar
  70. 70.
    Phillips M, Robinowitz M, Higgins JR, et al. Sudden death in Air Force recruits. JAMA 1986; 256: 2696–9PubMedCrossRefGoogle Scholar
  71. 71.
    Maron BJ, Carney KP, Lever HM. Relation of race to sudden cardiac death in competitive athletes with hypertrophic cardiomyopathy. J Am Coll Cardiol 2003; 41: 974–80PubMedCrossRefGoogle Scholar
  72. 72.
    Bauce B, Frigo G, Benini G, et al. Differences and similarities between arrhythmogenic right ventricular cardiomyopathyand athlete’s heart adaptations. Br J Sports Med 2010; 44: 148–54PubMedCrossRefGoogle Scholar
  73. 73.
    Link MS, Wang PJ, Pandian NG. An experimental model of sudden death due to low energy chest wall impact (commotiocordis). N Engl J Med 1998; 338: 1805–11PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2011

Authors and Affiliations

  1. 1.Department of PediatricsBaystate Medical CenterSpringfieldUSA

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